- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,187.61 / $3,187.61 / $3,187.61
| Facility | | $3,187.61 | $3,187.61 | $3,187.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.61 / $3,187.61 / $3,187.61
| Professional | | $3,187.61 | $3,187.61 | $3,187.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,187.61 / $3,187.61 / $3,187.61
| Facility | | $3,187.61 | $3,187.61 | $3,187.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.52 / $1,978.52 / $3,187.61
| Professional | | $1,978.52 | $1,978.52 | $3,187.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.31 / $923.31 / $2,198.35
| Professional | | $923.31 | $923.31 | $2,198.35 |